Cultural Competence: More Than Just Language

MAY 01, 2007

Guido R. Zanni, PhD

Do clinicians need cultural competence?
More than 6000 languages
are spoken in the
world's 191 countries,1 and approximately
32 million Americans speak a total of
329 languages other than English in their
homes.2 Also, more than 1 million health
care workers are immigrants.3 The
absence of cultural competence, which
is qualitative and dynamic, is easier to
identify than its presence.

Culture encompasses language,
thoughts, communications, customs,
beliefs, values, and racial, ethnic, religious,
or social institutions. Competence
is the capacity to operate within the culture
effectively.2 Cultural competence
includes linguistic competence in the culture's
native language, as well as understanding
culturally specific nuances.

Even within a unique culture, terminology
and syntax can be unintentionally
offensive. Those suffering
from mental illness may bristle when
described as schizophrenic, preferring
to be described as persons suffering
from schizophrenia.

People express symptoms differently;
eg, some cultures use "fatigue"
interchangeably with "depression"

Prescription instructions translate
poorly into some languages

Patient belief systems impact access,
help-seeking behaviors, and treatment
adherence. Some Latin cultures maintain
that it is better
not to know if
you have cancer,
because little can
be done.1 In many
instances, culture
may dictate visiting
a physician
only when feeling
ill?eschewing
primary prevention
and routine
monitoring.
Cultures defined
by ethnic exclusivity,
family authority,
and skepticism
about medicine often delay treatment.2

Folklore can color the meaning of illness.
Some cultures associate breast
cancer with sinful behavior. Others consider
speaking about or planning for
one's death a bad omen. Ethnicity is the
second most common predictor of
patients'willingness to create advance
directives.4

Studies have found that Hispanics
were 7 times less likely to receive an
analgesic for pain than whites, and that
pediatricians were 17 times less likely
to prescribe nebulizers for home use to
Hispanic children.1 Among numerous
factors, language and cultural incompetence
are often suspect. For example,
women with limited English
receive fewer mammograms and Pap
smears.1 Perceived language problems
cause up to 20% of Spanish-speaking
individuals to refuse or delay treatment.2

Competence Matters

Patient and staff satisfaction increases
in settings emphasizing cultural competence.5,6 It is more than just psychological?
one study found increased adherence
among racial and ethnic minorities in
settings emphasizing respect and dignity.6

Poor competence undermines trust
and increases the likelihood of diagnostic
errors, inappropriate treatment, and poor
adherence.2 Studies indicate that African
Americans, Asians, and Hispanics, perceiving
bias and disrespect from clinicians,
believe that care would improve if
they were of a different group identity.7

Five Basic Interventions

Cultural competence is built on staff
recruitment, use of interpreter services
(Table 18,9), cultural competency training,
culturally appropriate client education
materials, and culturally specific health
care settings. An excellent tool for
assessing cultural competence on an
organization level can be found
at www.hrsa.gov/culturalcompetence/indicators/. Former Surgeon General
David Satcher recommends that staff
members think of the acronym CRASH:

C: Consider culture when you are
interacting with patients.

R: Respect other peoples'cultures,
and learn how respect is communicated
within those cultures.

A: Assess and affirm culture, including
positive feedback about the person's
culture.

S: Sensitivity to the other person's culture
and the impact of one's own
culture are key and must be
expressed.

H: Humility is needed, based on the
fact that few people become
experts in other cultures.10

Counseling Tips

Cultural competence is patient-centered.
One should avoid the common
error of myopically defining a person
within one cultural identity based on language
or ethnic origin. People have multiple
cultural identities that define them
in relation to others, and recognizing
these issues vastly improves counseling
(Table 211).

Final Thought

Clinicians were once encouraged to
detach themselves from patients, believing
that clinical accuracy was enhanced
by objective, nonpersonal interactions.
Yesterday's skill has become today's liability.
Effective heath care delivery
depends on cultural competence.

10. Satcher D, Ninan P, Masand P. A Surgeon General's Perspective on Cultural
Competency: What Is It and How Does It Affect Diagnosis and Treatment of
Major Depressive Disorder? Available at:
www.medscape.com/viewprogram/4489. Accessed February 20, 2007.